Referral source and outcomes of physical therapy care in patients with low back pain.

STUDY DESIGN: Retrospective longitudinal cohort. OBJECTIVES: To describe the clinical characteristics of patients with low back pain according to physician referral source, and to identify associations between referral source and discharge functional status, as well as number of physical therapy visits. BACKGROUND: Little is known about associations between physician referral source and outcomes of physical therapy care for patients with low back pain. Exploring these associations can contribute to better understanding of physician-physical therapist relationships and may lead to improved referral patterns. METHODS: Data from a proprietary clinical database were examined retrospectively. Physician referral source was classified as primary care, specialist, or occupational medicine. Outcomes were overall health status at discharge and number of physical therapy visits. Descriptive statistics and bivariate associations between referral source and each outcome were assessed by calculating differences and 95% confidence intervals (CIs) in means and proportions. To account for potential confounding, multilevel linear regression was used to adjust for baseline clinical covariates, effects related to clustering of patients treated by individual clinicians, and clinicians working within individual clinics. RESULTS: Bivariate and multilevel analyses revealed significant associations between referral source and discharge overall health status, as well as number of visits. After multilevel adjustment for covariate and clustering effects, primary care and occupational medicine referrals were associated, on average, with point increases of 1.6 (95% CI: 0.7, 2.6) and 4.8 (95% CI: 2.7, 6.9) in discharge overall health status scores, respectively, compared to specialist referral. Similarly, primary care and occupational medicine referrals were associated, on average, with 0.44 (95% CI: 0.27, 0.61) and 0.83 (95% CI: 0.44, 1.22) fewer visits, respectively, compared to specialist referral. CONCLUSION: After accounting for clinical covariates and clustering, patients with low back pain who were referred by occupational medicine and primary care physicians tended to have better functional outcomes and required fewer physical therapy visits per episode of care. LEVEL OF EVIDENCE: Prognosis, level 2c.

Is a prescriptive or an open referral related to physical therapy outcomes in patients with lumbar spine-related problems?

STUDY DESIGN: Retrospective review of medical records. OBJECTIVES: To describe characteristics of patients with lumbar spine dysfunction, and to compare functional outcome and number of visits to physical therapy according to type of physician referral. BACKGROUND: The type of referral, characterized as prescriptive or open, has been associated with the perceived amount of supervision that is required for the provision of physical therapy care. The rationale for prescriptive referrals is not consistent with autonomous physical therapy practice, and may be deemed unnecessary if such referrals are associated with equivalent outcomes. METHODS AND MEASURES: Medical records of patients treated within a rehabilitation provider network between October 2002 and December 2003 were reviewed retrospectively for administrative and clinical variables. Subjects were selected if they completed the Roland Morris Questionnaire (RMQ) on admission and discharge from physical therapy care. Associations between referral type, discharge RMQ scores, and number of visits were determined using independent t tests and were further examined using stepwise multiple regression analysis. RESULTS: Ninety-six records met inclusion criteria, of which 54 (56.2%) had open referrals and 41 (43.8%) had prescriptive referrals. Type of referral was not associated with number of visits in bivariate or in multivariate analysis. Prescriptive referrals were associated with higher discharge RMQ scores, representing greater disability, in bivariate analysis (t test, P = .03); however, this association was attenuated in multivariate analyses after adjustment for physician status as primary care practitioner or specialist. CONCLUSION: Prescriptive referrals were not associated with enhanced outcomes of physical therapy care.